Dietary practices, physical activity and social determinants of non-communicable diseases in Nepal: A systemic analysis

Unhealthy dietary habits and physical inactivity are major risk factors of non-communicable diseases (NCDs) globally. The objective of this paper was to describe the role of dietary practices and physical activity in the interaction of the social determinants of NCDs in Nepal, a developing economy. The study was a qualitative study design involving two districts in Nepal, whereby data was collected via key informant interviews (n = 63) and focus group discussions (n = 12). Thematic analysis of the qualitative data was performed, and a causal loop diagram was built to illustrate the dynamic interactions of the social determinants of NCDs based on the themes. The study also involved sense-making sessions with policy level and local stakeholders. Four key interacting themes emerged from the study describing current dietary and physical activity practices, influence of junk food, role of health system and socio-economic factors as root causes. While the current dietary and physical activity-related practices within communities were unhealthy, the broader determinants such as socio-economic circumstances and gender further fuelled such practices. The health system has potential to play a more effective role in the prevention of the behavioural and social determinants of NCDs.

methods section (and hence the use of same figure relating to methodology and study framework).] Please clarify whether this [conference proceeding or publication] was peer-reviewed and formally published. If this work was previously peer-reviewed and published, in the cover letter please provide the reason that this work does not constitute dual publication and should be included in the current manuscript. -This is the second paper from the PhD thesis and includes results about diet and physical activity. The first paper concentrated on results from the PhD focussing on tobacco and alcohol use (https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-09446-2) which has been peer-reviewed and published. Since the first published paper and this paper on diet and physical activity are from the first authors PhD thesis, we have used and referenced figures relating to the methods and study framework from the published paper in the submitted paper focusing on diet and physical activity. The introduction, findings and discussion are entirely different to the published paper and have not been published elsewhere and hence, we do not feel this constitutes dual publication.
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Reviewers' comments:
Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions?
The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly Reviewer #2: Yes Thank you for considering our manuscript as scientifically and technically sound. ________________________________________ 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: N/A We agree that statistical analysis is not applicable for this study. ________________________________________ 3. Have the authors made all data underlying the findings in their manuscript fully available?
The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data-e.g. participant privacy or use of data from a third party-those must be specified. Reviewer #1: No Reviewer #2: Yes We agree with reviewer 1 that still there is limitation in data availability and have shared that with editors. We are in the process of making data available public once we review the transcripts and make sure all personal identifiers of the respondents are removed, as Nepal is a small country and participants from policy level are easily identified. We hope to make the data publicly available by this year. ________________________________________ 4. Is the manuscript presented in an intelligible fashion and written in standard English?
PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes Thank you. ________________________________________ 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: This is a very interesting and mostly well-written paper. The authors utilize appropriate methods to draw their conclusions Some minor comments 1. Please consider using sex instead of gender, given you did not record one's gender. In case you measured one's gender, this should be more clearly presented in the methods -Thank you for your kind suggestion and we agree that we have not measured gender within this paper. However, gender reflects socially constructed characteristics of male and female. We have indeed provided some context such as Nepal being patriarchal society and having more social and economic power as a breadwinner of the family. Also, our findings and discussion are linking those gendered experiences with diet and physical activity related practices. Thus, we feel that it makes more sense if we keep the term "gender" within the manuscript.
2. The manuscript requires some English editing -The English has been reviewed by co-authors who are native English speakers. 3. Avoid using terms such as "causal relationship", "influence" etc. Given your study design cannot support these claims, please replace with association etc -Thank you for your kind suggestion. We have revised and replaced "causal relationship" with "association" accordingly. However, the term "Causal Loop Diagrams" is a standard method/tool name and we have not changed it. Also, as this is a qualitative study, keeping "influence(s)" made more sense (qualitative term) than replacing with "association" (quantitative term) and hence have decided to keep the term "influence (s)" as it is. Reviewer #2: Very timely and useful research. Probably, on of the most critical public health issue of our time is the growing burden of non-communicable disease. Most of these diseases are preventable and heavily dependent on behavior change. Changing people's behavior requires a thorough understanding of the root causes of behaviors and health system-related structural issue and the interlinkages with socialdeterminants of health leading to NCDs. The authors clearly described and organized their findings along these lines. Just two question. 1. Why were the study areas purposively selected? What was the rational for this judgment sampling rather than random selection? Was it to save time? I understand the application of the method to identify participants within the selected communities, as you stated because of their knowledge and experience. But, why were the communities selected through this method? -This is a qualitative study and often, cases are purposively chosen. In the study, the main purpose was to choose different context i.e. urban, semi-urban and rural settings, and was also selected in consultation with District Health Offices. Time and convenience of the first author (principal investigator) also influenced the choice of districts which is acceptable in purposive sampling. In qualitative studies, often random sampling is not the choice of sampling.
2. Most of the findings do not seem new. It would be helpful, if the authors emphasized on what is the key new knowledge versus what was already known. For example, we know urbanization, increasing availability and consumption of junk food, alcohol consumption, smoking and reduced physical activities are risk factors for NCDs. Is the key on the findings the Nepalese context? -The findings are especially important in Nepalese context where the focus is on changing behaviour. Yes, the findings may not be new for high-income countries but, for low income countries like Nepal, the authors hope that this paper can provide a whole new way of seeing a public health issue, taking a systems perspective and designing appropriate actions. This paper provides qualitative evidence on social determinants of dietary and physical activity practices which is very scarce in Nepalese (or low income country) and we hope that this provides some systemic insights for actions by concerned health agencies in Nepal. ________________________________________ 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.
If you choose "no", your identity will remain anonymous but your review may still be made public. In the article, we have highlighted the NCDs problem from systems perspective focusing on the role of two key behavioral risks factors i.e. dietary practices and physical activity. The article explores the complex causal mechanism of NCDs mediated by dietary practices and physical activity in Nepal through case analysis and causal loop diagrams which to our knowledge is first such research in the context of Nepal. We have addressed most of the comments from the peer reviewers and also explain the data availability related ethical issues.
Kindly consider the revised manuscript for publication. We declare no conflict of Interest. We accept all the terms and conditions of the journal to the best of my knowledge.

Abstract
Unhealthy dietary habit and physical inactivity are major risk factors of non-communicable diseases (NCDs) globally. The objective of this paper was to describe the role of dietary practices and physical activity in the interaction of the social determinants of NCDs in Nepal, a developing economy. The study was a qualitative study design involving two districts in Nepal, whereby data was collected via key informant interviews (n=63) and focus group discussions (n= 12). Thematic analysis of the qualitative data was performed, and a causal loop diagram was built to illustrate the dynamic interactions of the social determinants based on the themes. The study also involved sense-making sessions with policy level and local stakeholders. Four key interacting themes emerged from the study describing current dietary and physical activity practices, influence of junk food, role of health system and socioeconomic factors as root causes. While the current dietary and physical activity-related practices within communities were unhealthy, the broader determinants such as socioeconomic circumstances and gender further fuelled such practices. The health system has potential to play a more effective role in the prevention of the behavioural and social determinants of NCDs. Unhealthy dietary habit and physical inactivity have been identified as key risk factors in 2 increasing non-communicable diseases (NCDs) in developing countries [1,2]. It has been 3 estimated that dietary and physical activity risks attribute to approximately 5.3 million 4 premature deaths annually [3]. In Nepal, the last Stepwise approach to surveillance (STEPS) 5 survey has shown that about 99% of people did not consume sufficient fruits and vegetables 6 but only 3% did not have adequate physical activity [4]. However, the problem of physical 7 inactivity was more pervasive in the urban and peri-urban areas with more than 5% of urban 8 respondents categorised as physically inactive [4]. A recent study showed that inadequate 9 physical activity among adolescents was 85%, indicating the shift towards physical inactivity       Data collection 70 Data collection involved semi-structured interviews with key stakeholders from the case 71 districts and policy level. Policy level data were collected to supplement the information from 72 case districts. Semi-structured interview guideline so developed were guided by the adapted 73 social determinants of health framework (Fig 2).      One key observation highlighted by participants from the case districts was that the   In addition, participants stressed that increased motorisation and lack of systemic 231 infrastructure were leading to limited physical activity in the case studies. There has been a 232 rapid development in road infrastructure and motorisation of public and private transport 233 systems. However, due to lack of awareness regarding active travel and luxury-seeking 234 behaviour, this has been contributing to physical inactiveness to some extent.     Awareness-raising campaigns and multi-sectoral coordination for promoting sustainable food 334 systems and physical activity-friendly environments were lacking for prevention of NCDs.

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The health system was possibly guided by the mental model that unhealthy diet and physical 336 inactivity were more due to individual behaviour, hence the interventions in developing 337 countries were limited to campaigns and medical services provision. The CLD highlighted 338 the themes indicating that multi-sectoral coordination for sustainable food systems and 339 improving physical infrastructure were continually neglected by the overall health and social 340 system. The themes also indicated that junk food companies are using various tactics to 341 promote their products as a healthier option. The same sub-system hints at the curative 342 orientation of the health system (i.e. the increasing chronic diseases problem in turn put 343 pressure on the government to provide curative care services, leaving limited resources for 344 preventative actions, including multi-sectoral coordination). Demand-supply sub-system (Fig 4) highlights how individuals and communities were being  Socio-economic sub-system (Fig 5) can be conceptualised to distally drive the other two sub- The causal association of the diet and physical activity with NCDs was complex and is 377 discussed here in the light of existing evidence and from a systems perspective. Specifically, 378 we utilise system archetypes (Fig 6), a simpler version of CLDs, to present the mechanism in 379 a way that generates insights for health system action [34]. In this study, prevention-delay sub-system indicated that the health system has not been 386 structured and functioning effectively to promote healthy behaviours relating to diet and 387 physical activity. The health system in many developing countries like Nepal is yet to  action has been contributing to inadequate physical activity around the world [46,47]. 406 Prevention delay sub-system has illustrated that disease prevention and health promotion 407 efforts in Nepal have been offset by systemic issues within health system. As a result, 408 complex problems like NCDs continue to persist and there is tendency of health system to 409 focus on easily implementable solutions than a comprehensive approach which require health 410 system strengthening. This can be captured by the Shifting Burden archetype (Fig 6B). Many    Often, the junk food companies through quality advertisements would associate their 437 products with some social services or claim their products to be nutritious and can be enjoyed 438 by an entire family [65]. Such practices of social marketing and misleading vulnerable 439 population has been well documented in developed and developing countries [65][66][67]. Similar 440 to the findings of this study, a report identified the price factor, easy availability and lack of 441 government control were some of the factors that were leading to families providing children 442 with junk food [65].      Further, the interaction of the socio-economic sub-system with the prevention delay sub-525 system (as shown in CLDs) is yet to be appreciated by the health system, thus resulting in 526 limited action on social determinants of NCDs. This continuous ignorance of socio-economic 527 determinants of NCDs by the health system closely resonates with Shifting the Burden 528 archetype (Fig 6E). This CLD model and its archetypes could provide critical insights to            The study was a qualitative study design involving two districts in Nepal, guided by systemic intervention methodology. Qualitative data were collected through and collection of datawhereby data was collected via key informant interviews (n=63) and focus group discussions (n= 12). Thematic analysis of the qualitative data was performed carried out and a causal loop diagram was built to, and case study-based thematic analysis was carried out.
Causal loop diagram was utilised to illustrate the dynamic interactions of the social determinants based on the themes. The study also involved sense-making sessions with policy level and local stakeholders.

Findings:
Four key interacting themes emerged from the study: i). d Dietary and physical activity practices have shifted significantly at community level contributing to increased risk of NCDs; ii). t The practice of healthy and locally produced meals was gradually being displaced by junk food and linked to junk food availability and declining agricultural activities; iii). h Health system was ineffective in preventing unhealthy practices; and, iv) g.
Gender and socioal-economic factors were driving the poorunhealthy dietary practices and physical inactivity.
Conclusion: While the current dietary and physical activity-related practices within communities were poor, the broader determinants such as socio-economic circumstances and gender further fuelled such practices. The health system has potential to play an effective role in the prevention of the behavioural and social determinants of NCDs.

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The study design was qualitative study based on systemic intervention (SI) methodology    The causal mechanism of influenceassociation of the diet and physical activity on with NCDs 383 was complex and is discussed here in the light of existing evidence and from a systems 384 perspective. Specifically, we utilise system archetypes (Ffigure 6), a simpler version of 385 CLDs, to present the mechanism in a way that generates insights for health system action In this study, prevention-delay sub-system indicated that the health system has not been 393 structured and functioning effectively to promote healthy behaviours relating to diet and 394 physical activity. to urban areas due to sudden exposed to urban lifestyle. A more critical observation is needed 519 to understand the level of autonomy and access to services of the women among different 520 socio-economic group in both rural and urban areas.